Medication Training

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Medication TrainingCurriculum to Teach Unlicensed

School Personnel How to Assist With Medications in the School Setting

Alabama Board of NursingAlabama State Department of Education

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Importance

• Many children may require medicine during school hours.

• All schools do not have a full-time school nurse.

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Importance

• School nurses need assistance to provide the required medicine for students.

• Previously, the principal designated a school employee or teacher to assist students with medicine.

• Now, the school nurse, in collaboration with the principal, will select the person to assist students with medication and provide training and supervision for this activity.

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Background

• This training program was developed to give the school employee or teacher more information about the process of giving medicines, how to do it, what to write down, and the expected results.

• The responsibilities of the school nurse and the unlicensed assistant are also provided.

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Related Issues: School Health

• The Nurse Practice Act

• The Alabama Board of Nursing Administrative Code

• Delegation by school nurses

• Americans with Disabilities Act

• Confidentiality and privacy

• Responsibilities of the school nurse

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Related Issues: School Health

• Responsibilities of the medication assistant• How to determine if nursing judgment is

necessary• Specific rules related to medicine• Necessary knowledge• Responsibilities related to controlled substances• Selection of the medication assistant by the

school nurse• Expected outcomes

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Issues Related to Medications

• The number of students with complex health conditions is increasing.

• In the past, many children with chronic illnesses attended a special school or did not go to school.

• Societal changes resulted in a focus on the health of children in Alabama schools.

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Issues Related to Medications in the Schools

• Taking medicines at school is a small part of the school’s approach to the health of its students.

• The goal in administering medicines to students at school is to promote optimal wellness in order to enhance their ability to learn.

• Not taking prescribed medicine at the right time; taking the wrong dose of medicine, or having a reaction to medicine are all things that can lead to difficulty for a student to learn.

• The school response is holistic---the child’s health is the broad goal--while aiding the child’s health is a goal of giving medicines in the school setting.

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• There is no special title for the unlicensed person selected by the school nurse to assist with giving medicines in the schools.

• In Alabama,the term “Medication Assistant” will be used to identify that individual chosen by the school nurse for training.

• A school nurse may be either a registered nurse (RN) or a licensed practical nurse (LPN).

Medication Assistant

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• There is a difference in educational preparation and scope of practice between the RN and LPN.

• The LPN’s nursing practice requires oversight and supervision by the RN.

• The RN may not be in a position to supervise the LPN’s employment relationship with a school, but the LPN is not allowed to practice in a school setting without oversight of the nursing care provided to students by the RN.

RNs and LPNs

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• The RN or LPN School Nurse is required to have a license issued by the Alabama Board of Nursing.

• The license represents that the RN or LPN has:

• Specialized knowledge,• Independent judgment, and • The fitness and capacity to practice.

Nursing License—What Does it Mean?

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• The Alabama Board of Nursing:– Regulates the nursing education programs in

Alabama.– Assures that before issuing a license, the individual

applicant meets all the legal requirements.– Assures that the applicant passes “state boards”---a

national examination that determines the individual’s knowledge and competence to practice nursing.

• The holder of a nursing license is under the authority of the Board of Nursing.

Alabama Board of Nursing

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The Nurse Practice Act

• The Alabama Board of Nursing was established in 1915 by the Alabama legislature.

• The “Nurse Practice Act” is the term used to refer to the statutes that established the Board and the foundational laws for nursing practice.

• The Alabama Board of Nursing Administrative Code contains the published regulations.

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The Nurse Practice Act

• The statute establishes the broad power and authority of the Board of Nursing and the regulations set out specifics.

• In calendar year 2000, the Board of Nursing began work with school nurses, educators, and school administrators to address how, and who gave medicines in the schools.

• Prior to December 3, 2001, school nurses could teach unlicensed school employees or teachers about medicines but could not delegate a nursing task or function to the unlicensed person.

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Delegation

• Delegation is defined in the Board of Nursing regulations.

• Chapter 610-X-2-.06 (2) states that delegation is “the act of authorizing a competent individual to perform acts supportive to registered nurses or licensed practical nurses in selected situations.”

• Delegation is a key issue because the licensed nurse retains responsibility for the task that is delegated to someone else---someone else performs the task but the nurse retains the responsibility for the outcome.

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Mission of the ABN

• The Alabama Board of Nursing’s legal mandate is the protection of public health, safety, and welfare.

• The Board held public hearings, meetings with interested persons, talked with school nurses and decided to provide clarification for school nurse practice.

• The Board of Nursing established a section in the Board of Nursing Administrative Code specific to school nurses.

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Alabama Board of Nursing Administrative Code

• School nurse practice is very different than working in a hospital, nursing home, clinic, or home health.

• The school nurse is responsible for the health of children in each school to which he or she is assigned by the local education agency.

• Giving medicines is only one area of responsibility for the school nurse.

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School Nurse Practice

• The Board of Nursing recognized the special nature of school nursing.

• The foundation of delegation by a school nurse is found in Alabama Board of Nursing Administrative Code Chapter 610-X-6, Standards of Nursing Practice.

• The section specific to school nurses is given to you so that you have a basic understanding of the school nurse’s responsibility in providing health services to children.

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Delegation by School Nurses

• The school nurse is accountable and responsible for the nursing care delivered to students under the nurse’s jurisdiction.

• Registered nurses or licensed practical nurses that provide nursing care in the school setting through the twelfth grade may delegate specific tasks to unlicensed assistive personnel.

• The registered nurse is accountable for determining the tasks that may be safely performed by the unlicensed assistive personnel following appropriate training and demonstration of competency.

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Delegation by School NursesThe specific delegated tasks shall not require the exercise of independent nursing judgment or intervention. Specific tasks that require independent nursing judgment or intervention that

shall not be delegated include, but are not limited to:

• Catheterization, clean or sterile.

• Administration of injectable medications, other than premeasured medication for allergic reactions (i.e., EpiPen).

• Administration of rectal or vaginal medications.

• Calculation of medication dosages other than measuring a prescribed amount of liquid medication or breaking a scored tablet.

• Tracheotomy care, including suctioning.

• Gastric tube insertion, replacement, or feedings.

• Invasive procedures or techniques.

• Sterile procedures. • Ventilator care. • Receipt of verbal or

telephone orders from a licensed prescriber.

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• The task of providing prescribed oral, topical, ear, eye, nasal, and inhalation medications to a student through twelfth grade may be delegated to unlicensed assistive personnel by the school nurse only when the following conditions are met:

a. The school nurse identifies the appropriate individual(s) to assist in providing prescribed medications.

b. The unlicensed assistive personnel selected by the school nurse shall attend a minimum twenty-four hour course of instruction that includes a curriculum approved by the Board and demonstrated competency to perform the delegated task.


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• The school nurse shall provide periodic and regular evaluation and monitoring of the individual performing the delegated tasks.

• The school nurse shall routinely and periodically conduct quality monitoring of the tasks performed by the unlicensed assistive personnel, including, but not limited to:

a. Training b. Competency c. Documentation d. Error reporting e. Methods of identification of the right student, the right tasks,

the right method, and the right quantity at the right time.


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• The school nurse delegating the task may, at any time, suspend or withdraw the delegation of specific tasks to unlicensed assistive personnel.

• The SDE School Nurse Consultant or LEA School Nurse Administrator shall submit a report(s) to the ABN in a format specified by the Board upon request.

Author: Alabama Board of Nursing.Statutory Authority: Code of Alabama, 1975, § 34-21-2(c)(21).History: September 29, 1982. Repealed and Replaced: Filed

October 29, 2001. Effective December 3, 2001.

Suspending Delegation and Reporting

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Americans with Disabilities Act

• The Americans with Disabilities Act (ADA) is a federal law enacted by Congress to prohibit discrimination against the disabled.

• Prior to the ADA, individuals with special needs or disabilities were often unable to attend school (or work) because of barriers imposed by the physical layout of buildings, societal beliefs, and a lack of resources for the disabled.

• The law resulted in changes and removal of barriers---including the education of disabled children.

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ADA, IDEA, and 504

• Providing health care in the school setting became an expectation and resulted in passage of the Individuals with Disabilities Education Act (IDEA).

• These laws, when read together, provide a foundation for the health services the schools are required to provide students.

• Section 504 of the Rehabilitation Act of 1973 is a civil rights act.

• Section 504 prohibits discrimination solely on the basis of a disability in programs or activities that receive federal financial assistance.

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What Does it Mean?

• All LEAs in Alabama receive federal financial assistance and therefore, all LEAs must comply with Section 504 of the Rehabilitation Act of 1973.

• Other agencies have regulations that have to be considered by the school nurse and the medication assistant. – The federal Drug Enforcement Agency (DEA) has

jurisdiction over controlled substances. Narcotics or other “scheduled drugs” are referred to as controlled substances.

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What Does it Mean?– Doctors are required to have a specific DEA

number to write prescriptions for controlled substances.

– The Alabama Board of Pharmacy has regulations regarding the dispensing, packaging, and distribution of medications by pharmacists and pharmacies.

• Board of Pharmacy regulations impact medicines in the schools---particularly field trips and off-campus events.

– The Alabama Department of Public Health has regulations about reportable events, communicable diseases, and other public health issues.

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Confidentiality

• Confidentiality is an important legal concept in the school setting.

• Health records of students are confidential and are kept separate from the school records.

• Knowing some information from the health record is necessary for the medication assistant.

• It is important for the medication assistant to understand that the information provided should not be repeated to other students, school employees and teachers.

• Health records contain sensitive information and disclosure without permission can result in legal liability.

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Privacy

• Privacy is a separate legal concept. • If a child tells a teacher or school secretary how he or

she feels about having a chronic illness, that is information that should be shared with the school nurse but not disclosed to those who do not have a “need to know.”

• Students, teachers, and staff spend a great deal of time together over the course of a school year.

• It is natural for individuals to talk about situations at school.

• Recognize that health information has a higher level of protection.

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There are some practices that help protect the confidentiality and privacy of students, such as:

• Limit access to school health records as defined by policy.

• Discuss medication information with appropriate staff only.

• Require signature for all non-school health employees accessing health records.

• Secure records, avoid public disclosure.• Use appropriate areas for medication and avoid

discussion in public areas.• Refer all release of information requests to the school

nurse.

Confidentiality and Privacy

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• Purpose is to protect the health, safety, and welfare of the student.

• Some requirements include: – protecting the student’s rights, – managing and monitoring student’s prescribed

medicines, – using correct methods to identify students and

medicines, and – following guidelines for safety in assisting the school

nurse with medications (including storage of medicines and documentation).

Confidentiality and Privacy

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Responsibilities of the School Nurse

The responsibilities of the school nurse for administration of medications to students are:

• Development and implementation of the nursing care plan/individualized healthcare plan (IHP) including assessment, nursing diagnosis, establishment of nursing goals and evaluation.

• Ongoing assessment, evaluation of outcomes and revisions to the IHP.

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• Understands that any intervention that requires professional nursing knowledge, judgment, and/or skill may not be delegated.

• Assures the availability of resources required to assist with medications, including material resources, an appropriate environment, and supervision.

• Implements procedures for handling, storing, and disposing of medications per state and local guidelines.

The School Nurse:

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• Ensures that the medication assistant has successfully:– completed an ABN approved training program, – completed LEA and school specific training– received student specific instruction.

• Ensures ongoing competence of medication assistant by:– routine monitoring and observation – reviewing the documentation – re-teaching and correcting actions as needed. – documenting monitoring and corrective actions

Responsibilities of the School Nurse

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• Stability of the student’s health status

• Complexity of the task

• Competency of the medication assistant

• Compliance with health records and confidentiality

• Clear, written, signed medical order and written parental consent

The School Nurse delegates assistance with medication based upon:

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• Establishes procedures to ensure that the medication assistant has access to a healthcare professional at all times.

• Develops procedures for student specific routine and emergency procedures including:– assisting with medication while at school, – during school-sponsored trips and activities, – and during transportation to and from school.

• Performs delegation in accordance with the Alabama Nurse Practice Act.

Responsibilities of the School Nurse in Delegation…

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Responsibilities of the Medication Assistant• Successfully completes:

– an ABN approved program for medication assistance by unlicensed school personnel

– training specific to the LEA and school– training in student specific issues.

• Adheres to local policies and procedures.

• Follows the outlined plan of care for individual students.

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• Does not participate in activities that require:– professional nursing judgment, knowledge, or skill

• Notifies the school nurse when professional nursing care is required.

• Notifies the school nurse immediately when there is:– suspicion of a medication reaction, – a medication error,– change in a student’s health status.– new medication received at school

• Completes timely, accurate documentation in accordance with state and local policies.

Responsibilities of the Medication Assistant

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Definitions of Nursing Judgment

• The intellectual process a nurse exercises in forming an opinion and reaching a clinical decision based upon an analysis of evidence or data (ANA, 1992).

• The task does not involve ongoing assessment, interpretation or decision-making which cannot be logically separated from the performance of the task itself (NASN, 1996).

• Observations regarding the outcome and the student’s reaction to the task may be recorded, but nursing judgment is not needed in the performance of the task (NASN, 1996).

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Specific Rules Related to Medicine

• In order to assist students with medications in the schools, the medication assistant must successfully complete a training program approved by the ABN.

• Only registered nurses, physicians, or dentists may delegate assistance with medication to trained medication assistants in the school setting.

• A licensed practical nurse may delegate after determination by the registered nurse that delegation is appropriate.

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• No prescription medication may be given without:– parent authorization, – a healthcare provider order, and a – pharmacy label.

• Review local policies.

Specific Rules Related to Prescription Medicine

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• Under no circumstances should the school stock over-the-counter (OTC) medicines, such as Tylenol, for student or staff use.

• OTC must be provided by the parent in the original container with specific instructions as to when or why such medicines may be necessary.

• The delegating RN must evaluate and approve all OTC medicines and parental instructions.

• The delegating RN will determine if the OTC medicine is appropriate and whether a provider order is also necessary.

Specific Rules Related to OTC Medicine

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Necessary Knowledge

• Medications and how they are used. • Oral medications are packaged as

pills/tablets/capsules. • Changing the form of an oral medication can

only be done with authorization from the health provider and the delegating school nurse.

• Cutting, crushing, or sprinkling of the medication are examples of changing the form of an oral medication.

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• Scored tablets are made to be cut in half to obtain a smaller dose. – For example, the prescription may indicate each

tablet is 10 milligrams, but the order indicates the student is to take only 5 milligrams (requiring cutting).

• If a student has medication that must be cut, call the delegating school nurse. – Do not try to cut a scored tablet with a knife—a pill

cutter is used for that purpose and cleaned after each use.

• Coated tablets are swallowed whole and should not be chewed. Example: Advil.

Necessary Knowledge

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• Capsules are made to be taken by mouth and swallowed whole—do not take apart, crush, or permit the student to chew.

• Drug actions and possible negative reactions. • Trained observation skills. • Use of the Six Rights:

1. right student2. right medication3. right dose4. right time5. right route6. right documentation

Necessary Knowledge

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• Importance of checking the Six Rights each and every time medication is given: – (1) when taking medication from the cabinet, – (2) when pouring the medication, and – (3) when returning the medication to the cabinet.

• Appropriate, accurate, timely documentation. • How to obtain assistance from the school nurse

and/or other healthcare professionals. • Understanding of local policies.

Necessary Knowledge

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Responsibilities Related to Controlled Substances

• Identifies controlled substances and stores in a secure location according to state and local policies.

• Documents the receipt, number, and return of controlled substances according to state and local policies.

• Reports discrepancies in the quantity of a controlled substance to the school nurse, principal and other authorities according to state and local policies.

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Selection of the Medication Assistant by the School Nurse

• The unlicensed school personnel chosen to receive delegation must have successfully completed an ABN approved training program.

• The person assisting children with medications must be able to:– provide dedicated time, – in a quiet environment – without distractions, until the process is complete.

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Selection of the Medication Assistant by the School Nurse

• The person selected to assist students with medications should be able to:– successfully verbalize the concept of nursing judgment – notify the school nurse when nursing judgment is

required – demonstrate competence in all aspects of assisting

students with medicines as outlined by state and local policies

– establish and maintain communication with the school nurse(s)

– verbalize the importance of communication in promoting safe assistance with medications.

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Expected Outcomes for Students

• Remain in school, maintain or improve health status, and improve his/her potential for learning.

• Receive medication as prescribed by a licensed prescriber.

• Demonstrate knowledge of the principle of self-care and responsibility through appropriate self-medication procedures.

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Common Health Conditions

• Allergies• Asthma/Reactive Airway Disease• Attention Deficit/Hyperactivity Disorder (ADHD)• Behavioral/Emotional/Psychosocial Disorders• Diabetes• Infectious Diseases• Seizures

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Allergies

• Each time an allergic person is exposed to an allergen, the immune system produces an antibody called IgE.

• The more of this antibody made, the more allergic the person becomes.

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Allergies

• It may take weeks, months or years to make a large amount of IgE, but once a reserve is built up, allergic symptoms start.

• When the allergen comes into contact with the IgE on the surface of the so-called mast cells (located in the nose, skin, eyes, intestinal tract and bronchial tubes), these cells release chemicals-particularly one called histamine-that cause the allergic symptoms.

• In rare cases this reaction may occur with a first exposure to the allergen.

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Allergies

Allergens include six (6) main categories:• Inhaled allergens: dust, pollen, fungi, smoke, perfume,

odors of plastics, etc.• Food allergens: wheat, eggs, milk, chocolate,

strawberries, shellfish, nuts, etc.• Drug allergens: aspirin, antibiotics and some serums.• Infectious agents: bacteria, viruses, fungi, animal

parasites, etc.• Contact allergens: chemicals, animals, plants, metal.• Physical allergens: heat, cold, light, pressure, radiation.• Other: insect stings/bites.

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Allergies

Common allergy symptoms include:– sneezing– sniffling– nasal stuffiness– itchy and runny nose (usually clear discharge/drainage)– tearing, itchy, red or swollen eyes– coughing– headache without fever– skin rash– hives

•Anaphylaxis is a severe allergic reaction!– Life threatening– Unable to breathe--due to swelling in the respiratory tract.

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Allergies

Medications that are commonly used for allergies include:

• Antihistamines: astemizole (Hismanal), brompheniramine maleate (Dimetame), certirizine hydrochloride (Zyrtec), chlorpheniramine maleate (ChlorTrimeton), clemmastine fumarate (Tavist), cyproheptadine hydrochloride (Periactin), diphenhydramine hydrochloride (Benadryl), fexofenadine hydrochloride (Allegra), loratadine (Claritin), promethazine hydrochloride (Phenergan), and triprolidine hydrochloride (Actidil).

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Allergies

• Corticoseroids: dexamethasone (Decadron), prednisolone, prednisone, may be in the form of tablets, nasal spray, or inhalant.

• Epinephrine (Epi Pen): emergency treatment for anaphylaxis.

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Allergies

Any time a child, or an adult takes a medicine, there may be side effects.

Common side effects from allergy medication include:

• Drowsiness

• Nervousness

• Irritability

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Asthma/Reactive Airway Disease

• Respiratory condition in which the air passages of the lungs and bronchioles tighten up--making breathing difficult.

• During an asthmatic episode, the membranes lining the airways become:– inflamed; swell; and thick mucus builds up – the muscles surrounding the airways go into spasm.

• With each breath---– the air must struggle through the narrowed breathing

tubes to make its way into and out of the lungs.

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Asthma/Reactive Airway Disease• With expiration,

– a high-pitched wheezing sound may be heard, often identified with asthma.

• There are common “triggers” of asthma episodes. – Exposure to air pollutants

• cigarette smoke or paint fumes.

– Allergens • pollens, mold spores and animal dander In some children, exercise

can cause an asthma episode.

• Other triggers include:• inhaling cold air• certain medications• infections of the respiratory tract• allergic reactions to certain foods• stress and emotional upset• injury to the airways.

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Common asthma symptoms include:• Coughing.• Wheezing.• Difficulty breathing/tight chest.• Rapid breathing/pulse.• Retraction of the ribs and collar bones seen

during breathing.• Flushed, moist skin.• “Hunched forward” sitting position.

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Medications commonly used for asthma/reactive airway disease are:

• Bronchodilators:– open the airways and may be used for treatment of acute or

chronic asthma symptoms. (given orally or by inhalation) • Albuterol (Proventil, Ventolin).• Metaproterenol (Alupent, Metaprel).• Ipratropium Bromide (Atrovent).• Salmeterol xinafoate (Serevent).• Levaluterol (Xopenex).• Pirbuterol (Maxair).• Theophylline (Theodur Extended-Release Tablets, Theo-Dur.

Sprinkle).

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• Nonsteroidal Anti-inflammatory: – medications used to prevent an asthma

episode rather than provide relief of acute symptoms. (Usually used with bronchodilators to maximize lung function and control inflammation.)

• cromolyn sodium (Intal).• nedocromil (Tilade).

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• Corticosteroids: – used for their anti-inflammatory action. (May

be given orally or inhaled.) • Prednisone.• Prednisolone.• Beclomethasone (Vanceril, Beclovent).• Triamcinolone (Azmacort).• Flunisolide (Aerobid).• Fluticasone proprionate (Flovent, Flonase).• Budesonide.

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• Common side effects asthma medications include – tremors; nervousness; irritability; headache; increased

heart rate; dry mouth/throat and insomnia. • When using more than one inhaler, always use

the bronchodilator first. • Wait five (5) minutes before using the second

inhaled medication. • Rinse the mouth after using an inhaled steroid is

to prevent thrush (infection of the mouth or throat).

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Attention Deficit/Hyperactivity Disorder

• ADHD is a developmental disorder affecting the behavior, attention and learning of children.

• Symptoms include:– distraction – trouble concentrating– impulsive and acting-out behavior.

• Many students diagnosed with ADHD have difficulty staying seated and may be fidgety.

• Others may sit quietly, daydream, and appear “spaced out”.

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Attention Deficit/Hyperactivity Disorder

The medications commonly used for ADHD are: • Central Nervous System (CNS) Stimulants:

– Methylphenidate (Ritalin).– Pemoline (Cylert).– Dextroamphetamine Sulfate (Dexedrine).

• Antidepressants:– Amitriptyline pamoate (Elavil).– Bupropion hydrochloride (Wellbutrin).

Common side effects of the medications used to treat ADHD include:– loss of appetite; insomnia; headache; nausea; abdominal

discomfort, and nervousness.

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Behavioral/Emotional/Psychosocial DisordersStudents may manifest these disorders by a number of signs

and symptoms.• Depression symptoms

– Feelings of helplessness, hopelessness– Loneliness, isolation or withdrawal– Feelings of sadness– Self-deprecatory statements– Suicidal ideas, expressions or attempts.

• Anxiety disorders – Panicky and cannot be calmed down.– Repetitious behaviors.

• Psychotic disorders:– Paranoid.– Hearing voices.– Hallucinations.– Delusions.– Withdrawal.

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Behavioral/ Emotional/Psychosocial Disorders

Medications commonly used are:• Antidepressants:

– Amitriptyline hydrochloride (Elavil)– Bupropion hydrochloride (Wellbutrin).– Clomipramine hydrochloride (Anafranil).– Desipramine hydrochloride (Pertofran).– Fluoxetine hydrochloride (Prozac).– Imipramine hydrochloride (Tofranil).– Paroxetine hydrochloride (Paxil).– Phenelzine sulfate (Nardil).– Sertraline hydrochloride (Zoloft).– Tranylcypromine sulfate (Parnate).

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• Antianxiety agents:– Buspirone hydrochloride (BuSpar).– Diazepam (Valium).– Oxazepam (Serax).– Chlordiazepoxide (Librium).– Lorazepam (Ativan).– Flurazepam (Dalmane).– Alprazolam (Xanax).

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• Antipsychotic agents:– Thioridazine (Mellaril).– Trifluoperazine (Stelazine).– Prochlorperazine (Compazine).– Chlorprothixene (Tractan).– Pimozide (Orap).– Haloperidol (Haldol).– Lithium carbonate (Eskalith, Lithonate, Lithobid).

• Common side effect of these medications used in managing behavioral/emotional/psychosocial disorders include:– nausea; vomiting; diarrhea; tremors; malaise (out of sorts

feeling); “spaced out”; dizziness; drowsiness; dry mouth; headache; sedation; and seizures.


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Diabetes

• Diabetes is a very serious metabolic disorder that prevents the normal breakdown and use of food, especially sugars (carbohydrates) by the body.

• In children, diabetes is caused by inadequate production of the hormone insulin by the pancreas, causing the blood glucose (sugar) to reach dangerously high levels.

• If not controlled, the high blood glucose levels will damage body organs.

• There are two types of diabetes: insulin dependent (Type 1) and non-insulin dependent (Type 2).

• Type 2 is usually seen in adults and overweight children and may or may not require insulin for management.

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Diabetes

• Type 1 diabetes is seen most often in children and youth and requires insulin injections.

• Blood glucose levels are checked during the day and insulin is administered to lower high blood sugar levels if needed.

• Food or glucose tablets/gel may be used to raise low blood glucose levels.

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Diabetes

• If the blood glucose level is too high or too low certain symptoms can occur causing the student to be unable to function and possibly become unconscious.

• High blood glucose levels may be caused by:– too much food– too little insulin– illness or stress.

• Low blood glucose levels may be caused by:– too little food– too much insulin – extra exercise.

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Diabetes

• Common symptoms of high blood glucose levels (Hyperglycemia) include:– frequent urination; dry skin; hunger; extreme thirst; blurred

vision; drowsiness, and nausea.

• Common symptoms of low blood glucose levels (Hypoglycemia) include: – shaking; anxiousness; dizziness; headache; irritability; sweating;

weakness, and unconsciousness.

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Diabetes

• Insulin is commonly used for children with diabetes. • Insulin is given by injection into the subcutaneous tissue

or by insulin pump that delivers a constant supply of insulin.

• Overweight children with non-insulin dependent diabetes may take oral medication.

• Oral medications generally cause fewer side effects than insulin.

• A health care plan should address:– when the school nurse is to be called, and if the student

becomes unconscious, the emergency plan to be followed.

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Infectious Disease

• Infectious diseases are illnesses caused by:– viruses, bacteria, fungi or parasites.

• Infectious diseases are considered contagious or communicable.

• The spread of infectious disease may occur by one or more of the following: – Airborne droplets entering the body via the airway.– Direct contact (skin to skin).– Ingestion (eating/drinking).

• The various types of infectious diseases commonly seen in school children are:– colds; flu; strep throat; impetigo; conjunctivitis (pinkeye);

pediculosis (head lice); ringworm; and gastroenteritis (nausea, vomiting, diarrhea, and stomach/abdominal cramps).

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Infectious Disease

Diseases for which students should have received vaccinations include:

• Diphtheria• Hepatitis A & B• Mumps• Measles• Polio• Rubella• Tetanus• Pertussis (Whooping Cough)• Varicella (Chickenpox)

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Infectious Disease

Antibiotics are commonly used for non-viral infectious diseases

• Penicillins: – Augmentin, amoxicillin, Amoxil, ampicillin, Unipen, Pen Vee K.

• Cephalosporins: – Ceclor, Duricef, Suprax, Keftab, Lorabid.

• Tetracyclines: – Vibramycin, Minocin.

• Sulfonamides: – Bactrim, Gantrisin, Septra, Pediazole, Zithromax, Biaxin

Common side effects for all antibiotics include:– Diarrhea, stomach upset/ache, rash, itching, and hives.

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Infectious Disease

Antifungal medications are used for infections produced by fungi:– Fluconazole: Diflucan.– Griseofulvin: Fulcin.– Miconazole: Monistat.– Nystatin: Nilstst, Mycostatin.– Terbinafine hydrochloride: Lamisil.

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Seizures• Seizures are a symptom of disordered functioning of the brain.

– caused by abnormal electrical activity within the nerve pathways in the brain.

– take many forms and may be caused by a variety of illnesses, trauma, and high fevers.

• The types of seizures are generalized: – absence (petit mal)– tonic-clonic (grand mal)– partial (focal)– simple and complex.

• The signs and symptoms will depend on the type seizure. • Generalized muscle contractions or jerking violently of the whole

body is characteristic of grand mal seizures.

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Seizures

• The muscle contraction or jerking of an extremity or two is generally a partial or focal seizure.

• In a child with diagnosed seizures, it is helpful to know the usual pattern of seizure activity.

• If the seizure activity changes, reporting that information to the school nurse is vital.

• Loss of or altered consciousness can occur as seizure activity or as a consequence of the seizure.

• It is not unusual for a loss of consciousness to occur following a grand mal seizure.

• This is referred to as the “postictal” period and may last from seconds to an hour or longer.

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Seizures

• Brief absence of movement, muscle twitches, movement or twitching on one side of the body only, staring into space, and a report of “loss of time” are other seizure symptoms.

• Myths include that the individual “swallows his tongue” during a seizure.

• The tongue falls back into the back of the throat and may block the airway but the tongue is not “swallowed.”

• Another myth is that a spoon or other object needs to be placed in the individual’s mouth during a grand mal seizure.

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Seizures

• If a grand mal seizure has started, – it is best to turn the student on his side – refrain from placing fingers or other objects in the

student’s mouth.

• Clenching of teeth and chewing are common in seizure activity and injury can occur if – an attempt is made to stop the seizure– place an object in the mouth, or – move the student during the seizure.

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Seizures

• Medications (often referred to as anti-convulsants) commonly used to control seizure activity include: – phenobarbital; phenytoin (Dilantin); – carbamazepine (Tegretol); – diazepam (Valium);– ethosuximide (Zarontin); – gabapentin (Neurontin); – valproate sodium (Depakene); – clonazepam (Klonopin); – lamotrigine (Lamictal); – primidone (Mysoline); – divalproex sodium (Depakote.)

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Seizures

• Common side effects from anticonvulsants include:– Headache– Sleepiness– Dizziness– Trembling– Nausea and vomiting– Blurred vision.

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How to Assist Students with Particular Types of Medications

•When the Board of Nursing established regulations that allowed school nurses to delegate certain medications to an unlicensed school employee or teacher—

– the route of the medication was specified rather than the names of medicines.

•An absolute prohibition exists for injectable medications. •School nurses are prohibited from delegating assisting with medications that must be delivered by injection except for pre-mixed anti-allergy injections (Epi-pen.)

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How to Assist Students with Particular Types of Medications

• Assisting with Oral Medications• Assisting with Nose Drops• Assisting with Eye (Opthalmic) Drops• Assisting with Eye Ointment• Applying Eye Patch• Assisting with Ear (Otic) Drops• Use of Hand Held Inhalers (Metered Dose Inhalers)• Common Problems in Using an Inhaler• Application of Skin Creams, Ointment and Salves• Assisting with Skin Applications

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Assisting with Oral Medications

• Check order form and pharmacy label for instructions.

• Assemble necessary equipment.

• ALWAYS wash your hands before giving any medication to a student.

• If the student will touch or handle the medication, they should wash their hands.

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Pills/Tablets/Capsules: – Pour the medication into a medicine cup, the cap of the medication

bottle, or a small paper cup.

• Ask the student to pick up the medication himself or herself and put into his/her mouth followed by 6-8 ounces of water.

• If the student is not physically able to pick up the medication and you have to place the medication inside the student’s mouth, you should put on gloves to avoid transferring any infection to the student or to yourself.

• Throw away gloves after each use (now contaminated). • Make sure that the student swallowed the medication.• Wash your hands. • Record results.

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Liquids: • Liquid medications must be precisely measured.

– DO NOT USE SILVERWARE OR PLASTIC SPOONS—these are not accurate measuring tools.

• Use a calibrated medicine cup, spoon or syringe. • When using a measuring cup, place it on a flat surface

and read it at eye level for accuracy. • Pour the liquid from the side of the medicine bottle

opposite the label (to protect the label). • Clean the outside of the bottle if needed after pouring. • Ask the student to pick up the medication cup himself or

herself and swallow all of the medication.

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• If the student is not physically able to pick up the medication and you have to place the medication inside the student’s mouth, you should put on gloves to avoid transferring any infection to the student or to yourself. Throw away gloves after each use (now contaminated).

• Make sure that the student swallowed all of the medication.

• Wash hands. • Record results.

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Assisting with Nose Drops

• Check order form and pharmacy label for instructions.

• Instruct the student to gently blow the nose (except in case of nosebleeds or other contraindications.)

• Assemble necessary equipment.

• Wash hands and apply gloves to both hands.

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Drops: • Draw the medicine into the dropper. • To properly regulate dosage, draw only the amount to be

administered.Spray: • Prepare the spray container as directed on label.• Have the student lie down and tilt the head backward by

elevating the shoulders.• Insert the dropper into the nasal passage and instill the

medicine or assist the student in self-administering if a nasal spray.


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• Wipe the dropper off with a clean gauze pad to remove mucus.

• Have the student remain in this position for several minutes to allow the medication to be absorbed.

• Note results.• Instruct the student not to blow his or her nose

unless absolutely necessary.• Discard gloves and wash your hands.• Record results.


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Assisting with Eye Drops

• Check the order form and pharmacy label.

• Read the instructions carefully.

• Be certain you know which eye is to be treated. Initials may be used to specify the eye that requires treatment. O.D. = right eye; O.S. = left eye; O.U. = both eyes

• Assemble the necessary equipment.

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• Wash hands and apply gloves to both hands.

• Explain the procedure and instruct the student that vision may be blurred temporarily after applying this medication.

• Have the student assume a comfortable position– either lying down or sitting in a chair with

support for the neck.


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• Gently wipe the area around the eye(s) to be treated with a gauze pad that has been moistened with normal saline or water to remove drainage.

• Use a clean pad for each wipe and stroke from the nose outward.

• Ask the student to tilt the head back and to look up at the ceiling.

• Gently pull the lower lid of the affected eye down and out, to form a pocket.


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• Holding the dropper near the lid, gently drop the prescribed number of drops into the pocket.

• To prevent the dropper from being thrust into the individual’s eye, it is good practice to support your hand by placing a finger on the individual’s forehead.

• Press the inner corner (where the eyelids meet) to prevent medication from entering the respiratory system.


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• Avoid touching the eyelid or lashes with the dropper.

• Avoid dropping the solution on the sensitive cornea

• (the clear, transparent front part of the eye).

• Ask the student to close the eye, blink several times but not to rub the eye.

• Discard gloves and wash your hands.• Record results.


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Assisting with Eye Ointment

• Check the order from the pharmacy label.• Read the instructions carefully. • Be certain you know which eye is to be treated. • Initials may be used to specify the eye that

requires treatment. O.D. = right eye; O.S. = left eye; O.U. = both eyes

• Assemble the necessary equipment.• Wash hands and apply gloves to both hands.

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• Explain the procedure—– (instruct the student that vision may be blurred temporarily after

applying this medication).

• Have the student assume a comfortable position– either lying down or sitting in a chair with support for the neck.

• Gently wipe the area around the eye(s) to be treated with a gauze pad that has been moistened with normal saline or water to remove drainage.

• Use a clean pad for each wipe and stroke from the nose outward.

• Ask the student to tilt the head back and to look up at the ceiling.

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• Gently roll the tube of medication between the palms of both hands. – This aids in warming the ointment so it can cover the eye evenly.

• Gently pull the lower lid of the affected eye down and out, to form a pocket.

• Beginning at the inner corner of the eye (next to the bridge of the nose) and working toward the outer eye, gently squeeze a thin ribbon of the medication on the surface of the lower lid. – To prevent the tube from being thrust into the student’s eye, it is

good practice to support your hand by placing a finger on the student’s forehead.

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• Have the student close the eye(s) and massage the area gently to spread the medication across the entire eye.– Avoid touching the eye or the eyelid with

tube.

• Discard gloves and wash your hands.

• Record results.

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Applying Eye Patch

• Check the order form and read instructions carefully. – Be certain you know which

eye is to be patched. – Initials may be used to

specify the eye that requires treatment.

– O.D. = right eye; O.S. = left eye; O.U. = both eyes

• Assemble necessary equipment. – The parent, prescriber, or

pharmacist should supply the eye pad(s).

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• Wash your hands and apply gloves to both hands.

• Explain the procedure to the student.• Place it gently over the student’s closed eye.

DO NOT TOUCH THE SIDE OF PAD THAT LIES on the student’s eye.

• Apply two or three strips of paper tape from the mid-forehead to below the ear.

• Discard gloves and wash your hands.• Record results.

Applying Eye Patch

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Assisting with Ear Drops

• Check the order form and pharmacy label.

• Read instructions carefully. – Be certain you know which

ear(s) is to be treated (right, left, or both).

• Assemble the necessary equipment

• Wash your hands.• Explain the procedures to

the student.

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• Warm the medication to body temperature by holding it in your hands for several minutes.

• Ask the student to lie on one side with the ear to be treated facing upward or, if sitting, to tilt the head away from the affected ear.

• Clean the outer ear carefully and thoroughly with cotton.

• Draw the medication into the dropper. To properly regulate dosage, draw only the amount to be administered.


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• Gently, pull the cartilage part of the outer ear BACK AND UP. Place the prescribed number of drops into the ear canal without touching the dropper to the ear.

• Advise the student to remain in the same position for a few minutes to avoid leakage of drops from the ear, and then cleanse the external ear with dry cotton balls.

• Wash your hands.• Record results.


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Use of Hand Held Inhalers

• Read the order form and pharmacy label and follow the instructions carefully.

• Wash your hands.• Assemble the inhaler

properly; observe the student assemble if self-administered.

• Remind the student to keep the tongue flat in the mouth. Otherwise, the medication will spray directly on the tongue.

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• Shake the cartridge to mix the medication.• Remove the cap and hold the inhaler upright.• Place the cartridge (with spacer if indicated) to

the student’s lips and tell the student to exhale through the nose.

• Remind the student to exhale only enough to get the air out of the lungs (so that the medication can get in. Forcing air out of the lungs will collapse the airways even further).


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• Have the student press down firmly on the cartridge while taking a deep breath.

• Tell the student to breathe slowly and deeply. Rapid or shallow breaths will not carry the medication into the lungs.

• Press the cartridge when the student starts to inhale. Timing is important. – Do not press hard. The dose is predetermined, so only one

dose will be released, regardless of the pressure applied.• Remove the inhaler and tell the student to hold his or her

breath and count to 10. – This will let the medication settle on the surface of the airways

and prevent the student from exhaling it immediately.


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• Tell the student to exhale slowly with the lips pursed.

• Have student rinse mouth.

• After the treatment, clean the inhaler thoroughly by removing the metal canister, then rinse the plastic container under warm water and dry thoroughly.


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• Note: If the student takes more than one or a combination of medications by inhaler, there must be directions to indicate which medication is to taken in what order. Your delegating school nurse should provide the directions.

• Wash your hands.• Record results.• NOTE: Most students will be able to self-

administer inhaler medicines with little to no assistance from an adult. The delegating RN will provide specific guidance to the medication assistant.


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Common Problems in Using an Inhaler

• Not taking the medication as prescribed, but taking either too much or too little.

• Incorrect activation. This usually occurs through pressing the canister before taking a breath. Both should be done simultaneously so that the drug can be carried down to the lungs with the breath.

• Forgetting to shake the inhaler. The drug is in a suspension, and therefore particles may settle. If the inhaler is not shaken, it may not deliver the correct dosage of the drug.

• Not waiting long enough between puffs. The whole process should be repeated to take the second puff, otherwise an incorrect dosage may occur, or the drug may not penetrate into the lungs.

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Common Problems in Using an Inhaler

• Failure to clean the valve. Particles may jam up the valve in the mouthpiece unless it is cleaned occasionally. This is a frequent cause of failure to get 200 puffs from one inhaler.

• Failure to observe whether the inhaler is actually releasing a spray. If it is not, call your delegating RN.

• A student’s need for bronchodilators more than every 4 hours can signal respiratory problems. Call your delegating RN.

• A simple method of estimating the amount left in the inhalant canister is to place the canister in a container filled with water. The position the canister takes in the water determines the amount of inhalant remaining.

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Application of Skin Creams, Ointment, and Salves

• Read the order form and pharmacy label. Follow instructions carefully.

• Wash hands and apply gloves.

• Apply small amount of cream to tips of gloved fingers

• Apply medicine to designated part of body.

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Assisting with Skin Applications

• Many locally applied drugs such as lotions, patches, pastes, and ointments can create systemic and local effects if absorbed through the skin. – To protect yourself from accidental exposure, apply these

drugs using gloves and applicators.

• Each type of medication, whether an ointment, lotion, powder, or patch, should be applied in a specific way to ensure proper penetration and absorption. – For example, lotions and creams are applied by spreading

them lightly onto the skin’s surface, whereas powders are dusted lightly over the affected areas.

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Assisting with Skin Applications

• If topical agent is present—– first wash site with mild, nondrying soap and warm

water.

• Carefully inspect the condition of the skin or membranes over which medications are to be applied.

• Discard gloves and wash your hands.• Contact your delegating RN if you have

questions or concerns.• Record the results.

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Safety

• The following requirements provide school personnel, parents, guardians, students, and health professionals with the guidance necessary to provide safe and proper assistance with medication in schools.

• The Alabama Board of Nursing (ABN) in collaboration with the Alabama State Department of Education (SDE) developed these requirements.

• This document is divided into the following sections: – Structure Criteria, – Process Criteria, – Outcome Criteria, and – an Appendix with required documentation forms.

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Safety

• The intent of this document is to provide the ABN, the SDE, and Local Education Agencies (LEAs) with information to establish and implement policies and procedures for consistent and safe assistance with medication required during school.

• Standards of nursing practice for Alabama were followed when developing this guidance.

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Safety

• NOTE: The authority for licensed school nurses administering medication to a student must come from the prescriber and the parent/guardian.

• The registered school nurse may decide, in certain situations, to delegate the assistance of medication (e.g., oral, topical, inhalation, eye, ear, or nose drops) to unlicensed school personnel (e.g., secretaries, office assistants) pursuant to the Alabama Board of Nursing Administrative Code, Chapter 610-X-6-.05.

• The licensed practical nurse in the school setting may delegate once the registered nurse determines the appropriateness of the delegation.

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Structure Criteria

Assisting students with medication requires the following:

• A signed authorization/order from a licensed prescriber

• Information regarding potential side effects, contraindications, and adverse reactions

• Parent/guardian authorization • Medication labeling • Medication storage • Assisting with medication

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A signed authorization/order from a licensed prescriber

• The signed prescriber’s authorization is required at the beginning of each school year and/or before any medication can be given at school. – If the medication order is changed during the school year

(e.g., change in dosage), an additional prescriber authorization/order is necessary (See Appendix for form).

• Nonprescription medications, if provided, should be given following the same policies and procedures as followed for prescription medications.

• Must include:– Name of student.– Name of medication with dosage and route (e.g., oral, topical). – Frequency and time medication given. – Date of the order and the discontinuation date, if applicable. – Any known drug allergies or reactions

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The signed prescriber’s authorization is required at the beginning of each school year and/or before any prescribed medication can be given at school. Oxygen requires an order from a licensed prescriber before it can be administered.

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Over the Counter Medications

NONPRESCRIPTION MEDICATIONS:Over the counter medications, when

provided, should be given following the same policies and procedures as followed for prescription medications with the exception of situations where the local medication policy requires parental/guardian permission only before administration of medication.

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Food supplements, natural substances and herbs are not without potential harm, including life-threatening conditions. Herbal products and dietary supplements have not been subject to the scrutiny of the FDA and in the US, as in most countries, dosage and purity have not been regulated for these products.

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It is not recommended that school personnel administer any substance that could be construed as a drug or medication, including natural remedies, herbs and nutritional supplements, without the explicit order of an authorized prescriber, parent authorization, verification that the product is safe to administer to children in the prescribed dosage and reasonable

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Information regarding therapeutic and untoward effects.

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Information Regarding Potential Side Effects, Contraindications, and

Adverse Reactions• A list of potential side effects for medication taken over

30 days and a physician order for treatment for specific students in the event of an adverse reaction should be obtained.

• This information should be readily available to school personnel who are eligible to assist students with medication.

• Information regarding medication side effects and treatment orders should also be documented by the registered school nurse in the student health record, the individual health care plan (IHCP), and/or the individual emergency action plan as applicable.

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Parent/guardian authorization

• The parent/guardian must sign the consent form at the beginning of the school year and/or before any medication is given at school authorizing school personnel to assist students with medication.

• If the medication order is changed (e.g., dosage change) during the school year, an additional consent form is required (See Appendix).

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Medication labeling

• For prescription medications, a pharmacy-labeled container is required which includes– the student’s name, prescriber’s name, name of medication,

strength, dosage, time interval, route, and date of drug’s discontinuation when applicable.

• If the medication will be provided for two weeks or longer, the parent/guardian should request two containers from the pharmacist, with one labeled for school use.

• When the medication to be provided is a nonprescription medication (OTC), an original container of the drug identifying the medication and the entire manufacturer’s labeling plus the student’s name (written legibly on the container) should be supplied by the parent/guardian.

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Medication Labeling

• Additionally, the parent must indicate under which specific conditions/complaints that this nonprescription or over the counter medication (OTC) should be provided.

• Unlicensed school personnel should not be placed in the position of determining when or what medication should be provided for a student (i.e., that determination requires nursing judgment which is prohibited for an unlicensed person to perform).

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Medication labeling

• To avoid this problem, the LEA may require a prescriber authorization/order for nonprescription (OTC) medications.

• Under no circumstances should the school stock OTC medications (e.g., Tylenol, Pepto-Bismol, antibiotic ointment) as this practice would violate the Board of Pharmacy regulations in that LEAs could be seen as “prescribing medication”, a function of physicians, dentists, nurse practitioners, and physicians’ assistants or “dispensing” medication, a function of the pharmacist.

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Medication Storage

• All medication should be stored in the original pharmacy or manufacturer’s labeled containers in such a manner as to render them safe and effective.

• Licensed or unlicensed school personnel must not repackage medication for field trips or other circumstances.

• Repackaging medications is a function of the pharmacist.

• Medications must be stored in a securely locked, clean container or cabinet, unless the prescriber authorizes a different arrangement (e.g., asthma inhalers) for specific students.

• Medications requiring refrigeration should be refrigerated in a secure area.

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Medication Storage

• Public health standards state that medications should not be stored in food storage areas.

• It is recommended that no more than a six-week, school day supply of the prescribed medication be stored at school.

• When the course of medication is completed, out of date, or at the end of the school year, the parent/guardian shall be advised to pick up any unused portions of medication.

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Medication Storage

• The school nurse or other school personnel designated by the school nurse in the presence of a witness will destroy medications not picked up by the parent/guardian.

• It is strongly recommended that medications should be discarded in a manner consistent with health department and/or LEA policy.

• Any discarded medication should be documented on the student’s medication record.

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Assisting With Medication

• After unlicensed school personnel successfully complete the ABN approved 24-hour medication course; the unlicensed personnel will be eligible for delegation from the school nurse to assist students with certain medications.

• Medications for students are to be provided by the parent/guardian.

• The first dose of a new medication or a change in dosage (increase or decrease) of a current medication should be given at home, with the exception of emergency medications (e.g., EpiPen injection).

• Most drugs used to treat attention deficit hyperactivity disorder (ADHD) are controlled substances and therefore require more attention to security measures.

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• The parent/guardian or parent-designated responsible adult should deliver all controlled substances (e.g., Ritalin) to the school nurse or other school employee as designated by the registered school nurse and the principal.

• Students must not deliver controlled substances to the school due to the potential for abuse.

• As a protection to LEA personnel and students, two employees (or the parent and a school employee) should also count these medications upon delivery and document the number of tablets or capsules delivered by the parent/guardian to the school.

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• If it is unclear whether a medication is a controlled substance, LEA personnel should contact the registered school nurse for clarification.

• The medication record allows for recording comments or problems related to assisting with medication.

• The record contains the student’s name, name of medication with dosage, date and time to be given, and possibly, the date to stop the medication.

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• Medication records should be signed with the full signature of the school nurse and/or the unlicensed school personnel delegated the task of assisting students with medication.

• If the same person gives the medication more than once, he/she may initial the record subsequent to signing a full signature.

• The required form to document assistance with medications is included in the Appendix.

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• This specific record should be kept for all students requiring medication.

• All medication records should be filed at the end of the school year as part of the student’s confidential health record and in accord with local policy.

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• It is suggested that each LEA develop specific guidelines to address the storage, restricted access, confidentiality, and transfer of such records as appropriate.

• Before assisting with any medication, the signed prescriber order/authorization should be reviewed carefully and attached to the medication record.

• Copies of the prescriber’s signed order/authorization for medication should also be filed and documented with the student’s school health record and included in the individual health care plan (IHP), developed by the registered school nurse.

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Self Administration of Medication•Self-administration means—

the student is able to consume, inject, instill, or apply prescription medication in the manner directed by the licensed prescriber, without additional assistance or direction. It is recommended that self-administration of medication be permitted only when the following requirements are met:

•The licensed prescriber indicates that self-administration of the specific medication is permitted on his/her signed order/authorization. •The consent form signed by the student’s parent/guardian indicates that the student may self-administer the medication.•The registered school nurse is reasonably assured that the student is able to identify and select the appropriate medication, knows the frequency and purpose of the medication as ordered, and follows the school self-administration procedures (e.g., safety and security precautions). •The registered school nurse has assessed and documented the student’s health status and abilities and determined self-administration to be safe and appropriate for this particular student.

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Self Administration of Medication

•The school nurse has developed and implemented a plan to monitor the student’s self-administration of medication, based on the student’s abilities and health status.

•The school nurse informs appropriate school personnel and administrators that the student will be self-administering a prescribed medication.

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Self Administration of Medication

•The school nurse collaborates with school personnel, student, and/or parent/guardian to determine a safe place for storing the medication while providing for student accessibility when the medication is needed. •Some medications such as asthma inhalers or emergency injections (e.g., EpiPens) should be kept “on person” or carried at all times by the student. •The school nurse evaluates the effectiveness of the plan and modifies as needed.

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Emergencies Related to Medications in Schools

• Schools should establish an ongoing relationship with local hospitals and local Emergency Medical Services (EMS) personnel to expedite a student’s transfer to a hospital or health-care facility in cases where emergency medical services are required (e.g., student having a serious adverse reaction to medication).

• Current emergency telephone number(s) should be available to permit school personnel to contact the parent/guardian in case of emergency.

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• Emergency procedures covering on-campus and off-campus occurrences need to be established.

• An emergency action plan, including EMS transport authorization by the parent/guardian, is advised for students with known life-threatening conditions as identified by a physician (e.g., anaphylactic reaction, asthma, cardiac disorders, diabetes, seizures, hemophilia).

• These students need to be identified to permit appropriate action to be taken in case of emergency during activities on- or off- campus.

• Such plans and procedures should be incorporated in each school’s crisis management or safety plan. – For example, the ready availability of an emergency injection

medication such as epinephrine (e.g., EpiPen) is needed for some students in the event of severe allergic reactions (e.g., bee stings).

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• EMS should be called for each student requiring emergency procedures.

• The decision to transport to a medical facility or to provide other emergency care will be made at the time of EMS arrival by EMS personnel in collaboration with the EMS medical control (physician), the school principal, the school nurse and the parent, if available.

• The decision should also be based on the individual health care plan (IHP) or emergency care plan developed earlier by the registered school nurse in collaboration with the physician, parent/guardian, student and other appropriate school personnel.

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• Attempts should be made to notify parents and the principal at the same time EMS is called and/or the student receives any emergency medication (e.g., EpiPen).

• In all cases where feasible and where the attending physician so advises, the student should be trained by his/her physician and/or the registered school nurse to give his/her own emergency injection (e.g., EpiPen) with school personnel acting as back up for the procedure.

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• Establishing an information system for properly monitoring emergencies in terms of notifying the parent/guardian, EMS, the registered school nurse, and the physician is advised.

• Written Unusual Occurrence Reports (UOR) should be completed and reviewed at least annually in an effort to revise policies and procedures in order to reduce unnecessary risk. This UOR form is included in the Appendix.

• In-service which provides “hands-on” training of the procedures to use in case of emergency should be provided at least annually for school personnel by the registered school nurse and other appropriate local personnel (e.g., physicians, EMS).

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Medication Errors

As soon as an incorrect dosage of medication is recognized, the medication assistant should initiate the following steps:

• Closely supervise and observe the student in the health room, office, or other designated place. If the student is in class when the error is determined, have the student escorted back to the health room or office. Do not leave the student alone.

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Medication Errors

• Observe the student. Note if any of the following are present: – Difficulty with breathing.– Change in skin color.– Swelling around eyes, face, and/or throat.– Skin rash. – Change in mental alertness.– Slurred speech.– Sick at stomach or vomiting. – Dizziness. – Abdominal pain. – Any other unusual complaints or observations.

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Medication Errors

• Identify the incorrect dose, time, and name of the medication taken by the student.

• Immediately have an adult notify the principal and the registered school nurse of the error.

• Simultaneously, contact the Alabama Poison Control Center at 1-800-462-0800 and provide the following information: – Name, dose, and time of the medication taken in error. – Age and approximate height and weight (see authorization form)

of student.– Name(s), dose(s), and time of last dose of other known

medication being taken by the student.

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Medication Errors

• Follow the instructions provided by the Poison Control Center if at all possible.

• If unable to complete their directions, explain the problems to the Poison Control Center to determine if the student should be transported for emergency medical care.

• Notify student’s parent/guardian and physician.• Do not delay initiating further action if unable to

reach the parent/guardian, physician, or registered school nurse.

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Medication Errors

• Submit a completed Unusual Occurrence Report within 24 hours to the delegating registered school nurse and document the following:– Student’s name.– Parent’s/guardian’s name and telephone number. – Specific statement regarding the medication error. – Persons notified and time of notification. – Poison Control Center instruction or physician’s

instructions. – Actions taken. – Condition and outcome of student

• (e.g., transported to hospital, sent home with parent).

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Medication Errors

• The registered school nurse should file a copy of the Unusual Occurrence Report (UOR) in the student’s health record and in the school’s quality assurance record.

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Medication Errors

• When an omission of medication is first recognized, immediately initiate the following steps: – Identify the student who missed the dose of medication.– Notify the principal or designee and contact the registered

school nurse. – The registered school nurse should use his/her professional

judgment to determine whether the remainder of the dose should be omitted, given, or whether physician contact is appropriate.

– Contact the parent/guardian.– Document all circumstances and actions taken on the student’s

health record and other reports required by the SDE and ABN. – Follow SDE and ABN requirements for reporting all errors,

including omissions on the Unusual Occurrence Report (UOR).

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Staff Training

Medication assistants should receive school-specific and student-specific training from the delegating registered school nurse prior to assisting students with medication. The training should be repeated at least annually and cover at a minimum the following areas:

•Legal requirements, state and local policies and regulations.

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• Oral, injection (e.g., EpiPens only), topical ointments, eye drops, or eardrops.

• Liquid medication should be measured in disposable, calibrated medicine cups rather than teaspoons or tablespoons.

• Importance of being sure that oral medications have been completely swallowed/ingested in the presence of the medication assistant.

Routes of Medication

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Injections• Injections required during the school day must be

administered by a licensed nurse (RN or LPN) unless the student is able and authorized to self-administer his/her own injection by the parent/guardian and prescriber (e.g., insulin).

• EXCEPTION: Emergency injections (e.g., EpiPen) are designed for delivery by nonmedical personnel and encouraged to be provided by the student or unlicensed school employee with the written consent of the parent/guardian and prescriber.

• Such medications are prescribed for children with severe allergic conditions and must be used immediately in order to be effective in preventing anaphylaxis (a life-threatening, rapid onset allergic reaction).

• Unlicensed school personnel (teachers, aides, and secretaries) are NOT to provide any other injections to student (e.g., insulin, solu-cortef, glucagon).

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Suppositories

• Vaginal or rectal suppositories (e.g., Diastat) may only be administered by the RN or LPN.

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• Medications should not be provided to a student who is vomiting or has vomited.

• If there is any discrepancy that might be injurious to the student, the medication assistant should refuse to provide the medication until clarification is received.

• Contact the LEA registered school nurse to obtain clarification, and, as necessary to notify the parent/guardian immediately that no medication will be given.

Contraindications

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• Possible signs and symptoms of adverse side effects, omission, or overdose.

• Documentation and procedures for assisting with medication.

• Proper handling, storage, and security measures to be followed during the school day, during field trips, and other school events. – (e.g., overnight trips).

• Emergency procedures including preparation for routine bus transportation, field trips, and unforeseen events. – (e.g., inclement weather, lockdown, and evacuation of school).

Staff Training

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School Nurse Shall:

• Review periodically, the implementation of the medication policy, related procedures, and documentation in the school and monitor all medication assistants who assist students with medication.

• Provide and document at least annual training for medication assistants who are eligible for delegation to assist students with medication.

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School Nurse Shall:• Consult with parents/guardians and prescribers to design

emergency plans as needed. – The plan should include possible side effects of medications

as well as possible behavioral signs and symptoms of adverse side effects, omission, or overdose.

• Develop an individual health plan (IHP) and health record for all students requiring long-term medications or having other special health care needs.

• File a copy of the prescriber and parent-signed authorizations for medication in the student health record.

• Enhance student’s knowledge about his/her health status and the medication(s) used to manage the health condition.

• Provide the required medication documentation to the ABN through an annual report and other documentation required by the SDE.

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• Follow the policy requirements for assisting students with medication.

• Assist students with medication in a safe and private setting, i.e. an area free of distractions and disruptions.

• Obtain proper identification from the student as determined by the delegating registered school nurse and LEA policy (e.g., picture I.D.).

• Check prescriber’s authorization against medication label and notify registered school nurse of any discrepancy. – (Do not give the medication if there is a discrepancy.)

Medication Assistant Shall:

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• Not give a different amount of medication or change the order in any way based on parental or student communication.

• Not accept any verbal orders from a physician or physician’s office personnel. (The RN or LPN school nurse must accept all physician orders).

• Assist student with medication as directed by the licensed prescriber and by the delegating school nurse.

• Record date, time, dosage, and signature on the medication record immediately following the time that medication was provided.

• Report any unusual occurrence, behavior, or observation immediately to the delegating school nurse and the school principal.

• Ask questions of the delegating registered nurse as necessary to provide a safe environment for students.

Medication Assistant Shall:

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Expectations

• Assisting a student with prescribed medications during the school day will enable the student to remain in school, to maintain or improve health status, and to improve potential for learning.

• The student will receive medication as prescribed by a licensed prescriber.

• The student will demonstrate knowledge of the principle of self-care and responsibility through appropriate self-medication procedures when applicable.

• Annual reports from the LEA to the SDE will provide continuing data to the ABN regarding the outcomes of permitting school nurses to delegate certain medications to medication assistants.

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EVALUATIONWritten Exam

Competency Exam

Medication Training

Documents

Transcript of Medication Training